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Basics of Treatment of Victims of Radiation Terrorism or Accidents

Basics of Treatment of Victims of Radiation Terrorism or Accidents. Niel Wald, M.D. Dept. of Environmental and Occupational Health University of Pittsburgh. Medical Radiation Problems. External Radiation Source: Local Radiation Injury Acute Radiation Syndrome

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Basics of Treatment of Victims of Radiation Terrorism or Accidents

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  1. Basics of Treatment of Victims of Radiation Terrorism or Accidents Niel Wald, M.D. Dept. of Environmental and Occupational Health University of Pittsburgh

  2. MedicalRadiation Problems External Radiation Source: • Local Radiation Injury • Acute Radiation Syndrome Radionuclide Contamination: • External • Localized in Wound • Internal

  3. LOCAL RADIATION INJURY: RADIODERMATITIS TypeManifestation I Erythema II Transepidermal Injury III Dermal Radionecrosis IV Chronic Radiodermatitis

  4. Local Injury: Transepidermal (Beta Radiation + Thermal Burns)

  5. Local Radiation Injury PXD14

  6. Local Radiation Injury PXD 22

  7. Local Radiation Injury PXD 90

  8. Local Radiation Injury Therapy AMPUTATION STAGES Upper Extremities Left Right 4 mo 5 mo 5 mo 5 mo 6 mo 7 mo 7 mo 10 mo 12 mo 17 mo

  9. Arteriole (post-irradiation)

  10. Local Radiation Injury PXD22

  11. Local Radiation Injury PXD 29

  12. Local Radiation Injury PXD 92

  13. Local Radiation Injury Diagnosis • Inspection: Erythema • Blood Flow: Thermography; Isotope scanning (201Tl scintigraphy); Skin laser Doppler. • Tissue Density and Hydration: MRI; CT; 67Ga scintigraphy; 111In-labeled anti-myosin antibody scan. .

  14. Useful Steps in Clinical Care of Local Radiation Injury • History and Physical Examination • Serial Blood Counts • Chromosome Analysis • Re-enactment of Accident • Frequent Color Photographs • Baseline Extremity X-rays • Ophthalmologic Slit Lamp Examination • Sperm Counts • Surgical Consult

  15. Local Radiation Injury Therapy • Analgesics, Antipruritics • Anti-inflammatories • Antibiotics as needed • Skin Growth Factors • Synthetic Occlusive Dressings • Surgical Intervention: • Debridement • Excision and Grafting • Amputation

  16. Diagnostic X-Ray Injury

  17. Diagnostic X-ray Injury: Repaired

  18. Acute Radiation Syndromes and Their Management • Key underlying pathophysiology at the cell and organ level • Description of syndromes • Diagnostic procedures • Clinical care 589-1

  19. Acute Radiation Syndromes • Underlying Cellular Radiation Effects • Mitotic inhibition • Cell killing • Organ malfunction • Vascular reactions • Clinical Manifestations • Hematological • Gastrointestinal • Neurovascular • Pulmonary

  20. Three Stage Kinetic Model

  21. ProdromalSymptoms & Signs NeurogenicVascular Anorexia Conjunctivitis Nausea Skin Erythema Vomiting Diarrhea Fever Weakness

  22. Radiation Erythema (PXD 10)

  23. Radiation Epilation (PXD 23)

  24. ARS: 45 Days post-Epilation

  25. ARS: Hematopoietic Form 38-C

  26. ARS: Hematologic Course

  27. Hematopoietic Syndrome Systemic Effects • Immunodysfunction • Increased Infectious Complications • Hemorrhage • Anemia • Impaired Wound Healing

  28. ARS: Gastrointestinal Form 38-D

  29. Mechanism of GI Syndrome(Gunter-Smith Hypothesis) 627-1

  30. GI Syndrome Systemic Effects • Malabsorption • Ileus • Vomiting • Abdominal distention • Fluid and Electrolyte Shifts • Dehydration • Acute renal failure • Cardiovascular • GI Bleeding • Sepsis

  31. ARS: Neurovascular Form EXCITATION PHASE 38-E

  32. Autonomic Nervous System 49-B

  33. HYPOTHALAMIC SYSTEM 322-1

  34. Neurovascular Syndrome Systemic Effects • Vomiting and Diarrhea within Minutes • Confusion and Disorientation • Severe Hypotension • Hyperpyrexia • Cerebral Edema • Convulsions - Coma • Fatal within 24 to 48 Hours

  35. ARS- Pulmonary Form (pre-exposure)

  36. ARS- Pulmonary Form (exudative stage)

  37. ARS- Pulmonary Form (fibrotic stage)

  38. Pulmonary Syndrome Systemic Effects • Early Phase • Dyspnea • Cough • Pulmonary Edema • Acute Respiratory Distress Syndrome • Late Phase • Interstitial Fibrosis • Interstitial Pneumonitis • Chronic Respiratory Distress Syndrome

  39. Acute Radiation Syndrome Clinical Management Problems • Psychological Stress • Infection • Bacterial, viral, fungal, CMV, herpes • Hemorrhage • Radiation Enterocolitis • Radiation Pneumonitis • Combined Injuries • Radiation plus trauma, burns, etc. 648-4

  40. General Treatment Plan for External Exposure • Provide Psychological Support • Professional • Family • Clergy • Use Symptomatic Treatment • Antiemetics • Analgesics • Prevent Infection and Hemorrhage • Reverse Isolation • Antibiotics • Blood Products

  41. General Treatment Plan (cont.) • Maintain Hydration and Nutrition • Fluids • Electrolytes • Nutrients • Encourage Cell Renewal • Growth Factors • Stem Cells • Control Inflammatory Response • Steroids • Vasodilators

  42. Psychological Stress Reducers • One Responsible Decision-Maker • Realistic Appraisal of Problem and Clear Communication • Credible Action Plan and Adequate Resources • Pre-Emergency Education

  43. Infection Problems Secondary to Radiation Pancytopenia • Invasion and colonization of rectal or colonic wall by normal flora • Activation of latent infections • Opportunistic infections • Gram Negative • Staphylococcus Aureus 56-J

  44. General Anti-Infection Measures in Radiation Pancytopenia • Control Bacterial and Fungal Flora of • Naso-Oro-Pharyngeal Tract • Gastrointestinal Tract • Avoid Disruption of Skin and Mucosa • Introduce Environmental Control • Use Optimal Regimen vs. Overt Infection

  45. Selective Bacterial Decontamination • Some Oral Agents that have been used: Nasopharyngeal Tract: • B-Lactam Resistant Penicillins p.o. and Bacitracin to nares Gastrointestinal Tract: • Trimethoprim-Sulfamethoxazole or Polymixin + above, or Polymixin + Nalidixic Acid and Amphotericin or Nystatin p.o. • CONSULT INFECTIOUS DISEASE, TRANSPLANT, or HEMATOLOGY/ONCOLOGY SPECIALISTS for BEST CURRENT THERAPY for IMMUNOSUPPRESSED PATIENTS

  46. Environmental Control in Radiation Pancytopenia • Air Filtration and Positive Pressure • Reverse Isolation Procedures • Dietary Considerations • Special Precautions for Skin Punctures • Limitation of Attending Personnel

  47. ARS: Environmental Control

  48. Bedside Debriding of Local Radiation Injury

  49. Preparation For Hematologic Complications In Radiation Pancytopenia Transfusions: Erythrocytes Platelets Growth Factors: GSF, GMCF, IL2, etc. Stem Cell Transplants: Autografts (Marrow, cord, PB) Isografts Homografts Xenografts (?)

  50. Infection Therapy in Radiation Pancytopenia Some Systemic Agents that have been used: • Aminoglycosides (Gentamicin,etc.) • most effective • Ureido-Penicillins (Ticarcillin,etc.) • synergistic vs. gram-negative • Monobactams • effective vs. gram-negative & no renal toxicity • B-Lactam Resistant Penicillins (Methicillin,etc.) • effective vs. S.aureus CONSULT INFECTIOUS DISEASE, TRANSPLANT, or HEMATOLOGY/ ONCOLOGY SPECIALISTS for BEST CURRENT THERAPY for IMMUNOSUPPRESSED PATIENTS 434-2

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